Signature Test page - Katherine West Health Board

Full name*

Position*

Company or organisation*

Do you need access to Communicare, our patient information recall system (if applicable)?*

Yes
No

Applicant’s Prescriber Number (if applicable):

Registration number:

Do you need Communicare training?*

Yes
No

Do you have a current membership or registration from relevant body e.g. AHPRA*

Yes
No

Please upload your current membership or registration from relevant body e.g. AHPRA

Accepted file types: jpg, gif, png, pdf, docx, Max. file size: 50 MB.

Do you have a current Criminal History Check?*

Yes
No

Please upload a copy of your Criminal History Check*

Accepted file types: jpg, gif, png, pdf, docx, Max. file size: 50 MB.

Do you have a Working with Children (Ochre) card?*

Yes
No

Please upload your Working with Children (Ochre) card*

Accepted file types: jpg, gif, png, pdf, docx, Max. file size: 50 MB.

Do you intend to use any health promotion materials?

Yes
No

If you are intending to use any health promotion material, please upload them. This will be forwarded to the KWHB Cultural and Health Literacy Resource Review (CAHLRR) committee for approval. Please refrain from advertising resources in the health centre until the resource have been approved via email confirmation from phc.ops@kwhb.com.au

If you are intending to use any health promotion material, please upload them here.*

Drop files here or

Accepted file types: jpg, gif, png, pdf, docx, Max. file size: 50 MB, Max. files: 5.

Acknowledgement*

I have read and understood the Privacy and Confidentiality Policy and Procedure
I have read and understood the Fleet Management Policy
I have read and understood the Cyber Security Policy
I have read and understood the Code of Conduct Policy
I have read and understood the KWHB Cultural Security Framework
I have read and understood the Child Safe Code of Conduct Policy

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